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Cash Before Chemo: Hospitals Get Tough

By BARBARA MARTINEZ
April 28, 2008; Page A1

LAKE JACKSON, Texas -- When Lisa Kelly learned she had leukemia in late 2006, her doctor advised her to seek urgent care at M.D. Anderson Cancer Center in Houston. But the nonprofit hospital refused to accept Mrs. Kelly's limited insurance. It asked for $105,000 in cash before it would admit her.

Sitting in the hospital's business office, Mrs. Kelly says she told M.D. Anderson's representatives that she had some money to pay for treatment, but couldn't get all the cash they asked for that day. "Are they going to send me home?" she recalls thinking. "Am I going to die?"

Hospitals are adopting a policy to improve their finances: making medical care contingent on upfront payments. Typically, hospitals have billed people after they receive care. But now, pointing to their burgeoning bad-debt and charity-care costs, hospitals are asking patients for money before they get treated.

Hospitals say they have turned to the practice because of a spike in patients who don't pay their bills. Uncompensated care cost the hospital industry $31.2 billion in 2006, up 44% from $21.6 billion in 2000, according to the American Hospital Association.

The bad debt is driven by a larger number of Americans who are uninsured or who don't have enough insurance to cover medical costs if catastrophe strikes. Even among those with adequate insurance, deductibles and co-payments are growing so big that insured patients also have trouble paying hospitals.

. . .M.D. Anderson says it went to a new upfront-collection system for initial visits in 2005 after its unpaid patient bills jumped by $18 million to $52 million that year. The hospital said its increasing bad-debt load threatened its mission to cure cancer, a goal on which it spends hundreds of millions of dollars a year.

The change had the desired effect: The hospital's bad debt fell to $33 million the following year.

Asking patients to pay after they've received treatment is "like asking someone to pay for the car after they've driven off the lot," says John Tietjen, vice president for patient financial services at M.D. Anderson. "The time that the patient is most receptive is before the care is delivered."

M.D. Anderson says it provides assistance or free care to poor patients who can't afford treatment. It says it acted appropriately in Mrs. Kelly's case because she wasn't indigent, but underinsured. The hospital says it wouldn't accept her insurance because the payout, a maximum of $37,000 a year, would be less than 30% of the estimated costs of her care.

Tenet Healthcare and HCA, two big, for-profit hospital chains, say they have also been asking patients for upfront payments before admitting them. While the practice has received little notice, some patient advocates and health-care experts find it harder to justify at nonprofit hospitals, given their benevolent mission and improving financial fortunes.

. . .Federal law requires hospitals to treat emergencies, such as heart attacks or injuries from accidents. But the law doesn't cover conditions that aren't immediately life-threatening.

At the American Cancer Society, which runs call centers to help patients navigate financial problems, more people are saying they're being asked for large upfront payments by hospitals that they can't afford. "My greatest concern is that there are substantial numbers of people who need cancer care" who don't get it, "usually for financial reasons," says Otis Brawley, chief medical officer.

Mrs. Kelly's ordeal began in 2006, when she started bruising easily and was often tired. Her husband, Sam, nagged her to see a doctor.

A specialist in Lake Jackson, a town 50 miles from Houston, diagnosed Mrs. Kelly with acute leukemia, a cancer of the blood that can quickly turn fatal. The small cancer center in Lake Jackson refers acute leukemia patients to M.D. Anderson.

When Mrs. Kelly called M.D. Anderson to make an appointment, the hospital told her it wouldn't accept her insurance, a type called limited-benefit.

"When an insurer is going to pay the small amounts, we don't feel financially able to assume the risk," says M.D. Anderson's Mr. Tietjen.

An estimated one million Americans have limited-benefit plans. Usually less expensive than traditional plans, such insurance is popular among people like Mrs. Kelly who don't have health insurance through an employer.

Mrs. Kelly, 52, signed up for AARP's Medical Advantage plan, underwritten by UnitedHealth Group Inc., three years ago after she quit her job as a school-bus driver to help care for her mother. Her husband was retired after a career as a heavy-equipment operator. She says that at the time, she hardly ever went to the doctor. "I just thought I needed some kind of insurance policy because you never know what's going to happen," says Mrs. Kelly. She paid premiums of $185 a month.

A spokeswoman for UnitedHealth, one of the country's largest marketers of limited-benefit plans, says the plan is "meant to be a bridge or a gap filler." She says UnitedHealth has reimbursed Mrs. Kelly $38,478.36 for her medical costs. Because the hospital wouldn't accept her insurance, Mrs. Kelly paid bills herself, and submitted them to her insurer to get reimbursed.

. . .After eight days, she emerged from the hospital. Chemotherapy would continue for more than a year, as would requests for upfront payments. At times, she arrived at the hospital and learned her appointment was "blocked." That meant she needed to go to the business office first and make a payment.

One day, Mrs. Kelly says, nurses wouldn't change the chemotherapy bag in her pump until her husband made a new payment. She says she sat for an hour hooked up to a pump that beeped that it was out of medicine, until he returned with proof of payment.

A hospital spokesperson says "it is very difficult to imagine that a nursing staff would allow a patient to sit with a beeping pump until a receipt is presented." The hospital regrets if patients are inconvenienced by blocked appointments, she says, but it "is a necessary process to keep patients informed of their mounting bills and to continue dialog about financial obligations." She says appointments aren't blocked for patients who require urgent care.

Once, Mrs. Kelly says she was on an exam table awaiting her doctor, when he walked in with a representative from the business office. After arguing about money, she says the representative suggested moving her to another facility.

But the cancer center in Lake Jackson wouldn't take her back because it didn't have a blood bank or an infectious-disease specialist. "It risks a person's life by doing that [type of chemotherapy] at a small institution," says Emerardo Falcon Jr., of the Brazosport Cancer Center in Lake Jackson.

Ron Walters, an M.D. Anderson physician who gets involved in financial decisions about patients, says Mrs. Kelly's subsequent chemotherapy could have been handled locally. He says he is sorry if she was offended that the payment representative accompanied the doctor into the exam room, but it was an example of "a coordinated teamwork approach."

On TV one night, Mrs. Kelly saw a news segment about people who try to get patients' bills reduced. She contacted Holly Wallack, who is part of a group that works on contingency to reduce patients' bills; she keeps one-third of what she saves clients.

Ms. Wallack began firing off complaints to M.D. Anderson. She said Mrs. Kelly had been billed more than $360 for blood tests that most insurers pay $20 or less for, and up to $120 for saline pouches that cost less than $2 at retail.

On one bill, Mrs. Kelly was charged $20 for a pair of latex gloves. On another itemized bill, Ms. Wallack found this: CTH SIL 2M 7FX 25CM CLAMP A4356, for $314. It turned out to be a penis clamp, used to control incontinence.

M.D. Anderson's prices are reasonable compared with other hospitals, Mr. Tietjen says. The $20 price for the latex gloves, for example, takes into account the costs of acquiring and storing gloves, ones that are ripped and not used and ones used for patients who don't pay at all, he says. The charge for the penis clamp was a "clerical error" he says; a different type of catheter was used, but the hospital waived the charge. The hospital didn't reduce or waive other charges on Mrs. Kelly's bills.

Twenty dollar latex gloves? Jesus Fucking Christ.

(via Atrios)

(CBS) People who believe the U.S. Supreme Court’s decision giving the 2000 presidential election to George W. Bush was politically motivated should just get over it, says Justice Antonin Scalia.

Scalia denies that the controversial decision was political and discusses other aspects of his public and private life in a remarkably candid interview with 60 Minutes correspondent Lesley Stahl, this Sunday, April 27, at 7 p.m. ET/PT.

"I say nonsense," Scalia responds to Stahl’s observation that people say the Supreme Court’s decision in Gore v. Bush was based on politics and not justice. "Get over it. It’s so old by now. The principal issue in the case, whether the scheme that the Florida Supreme Court had put together violated the federal Constitution, that wasn’t even close. The vote was seven to two," he says, referring to the Supreme Court’s decision that the Supreme Court of Florida’s method for recounting ballots was unconstitutional.

Furthermore, says the outspoken conservative justice, it was Al Gore who ultimately put the issue into the courts. "It was Al Gore who made it a judicial question…. We didn’t go looking for trouble. It was he who said, 'I want this to be decided by the courts,'" says Scalia. "What are we supposed to say -- 'Not important enough?'" he jokes.

In short:

If we didn't have a Congress run by an incumbency protection racket, I'd say impeachment is too good for the slimebucket.

Lynndie England, the public face of the Abu Ghraib prison scandal, told a German news magazine that she was sorry for appearing in photographs of detainees in the notorious Iraqi prison, and believes the scenes of torture and humiliation served as a powerful rallying point for anti-American insurgents.

In an interview with the weekly magazine Stern conducted in English and posted on its Web site Tuesday, England was both remorseful and unrepentant — and conceded that the published photos surely incensed insurgents in Iraq.

"I guess after the picture came out the insurgency picked up and Iraqis attacked the Americans and the British and they attacked in return and they were just killing each other. I felt bad about it ... no, I felt pissed off. If the media hadn't exposed the pictures to that extent, then thousands of lives would have been saved," she was quoted as saying.

Asked how she could blame the media for the controversy, she said it wasn't her who leaked the photos.

"Yeah, I took the photos but I didn't make it worldwide. Yes, I was in five or six pictures and I took some pictures, and those pictures were shameful and degrading to the Iraqis and to our government," she said, according to the report.

Yep, it's not her fault, she wanted to keep the torture private. What a perfect Republican.

Exhaustive review finds no link between Saddam and al Qaida By Warren P. Strobel

WASHINGTON — An exhaustive review of more than 600,000 Iraqi documents that were captured after the 2003 U.S. invasion has found no evidence that Saddam Hussein's regime had any operational links with Osama bin Laden's al Qaida terrorist network.

The Pentagon-sponsored study, scheduled for release later this week, did confirm that Saddam's regime provided some support to other terrorist groups, particularly in the Middle East, U.S. officials told McClatchy. However, his security services were directed primarily against Iraqi exiles, Shiite Muslims, Kurds and others he considered enemies of his regime.

The new study of the Iraqi regime's archives found no documents indicating a "direct operational link" between Hussein's Iraq and al Qaida before the invasion, according to a U.S. official familiar with the report.

He and others spoke to McClatchy on condition of anonymity because the study isn't due to be shared with Congress and released before Wednesday.

In the first insider account of Pentagon decision-making on Iraq, one of the key architects of the war blasts former secretary of state Colin Powell, the CIA, retired Gen. Tommy R. Franks and former Iraq occupation chief L. Paul Bremer for mishandling the run-up to the invasion and the subsequent occupation of the country.

Douglas J. Feith, in a massive score-settling work, portrays an intelligence community and a State Department that repeatedly undermined plans he developed as undersecretary of defense for policy and conspired to undercut President Bush's policies.

Among the disclosures made by Feith in "War and Decision," scheduled for release next month by HarperCollins, is Bush's declaration, at a Dec. 18, 2002, National Security Council meeting, that "war is inevitable." The statement came weeks before U.N. weapons inspectors reported their initial findings on Iraq and months before Bush delivered an ultimatum to Iraqi leader Saddam Hussein. Feith, who says he took notes at the meeting, registered it as a "momentous comment."

Although he acknowledges "serious errors" in intelligence, policy and operational plans surrounding the invasion, Feith blames them on others outside the Pentagon and notes that "even the best planning" cannot avoid all problems in wartime. While he says the decision to invade was correct, he judges that the task of creating a viable and stable Iraqi government was poorly executed and remains "grimly incomplete."

Powell, Feith argues, allowed himself to be publicly portrayed as a dove, but while Powell "downplayed" the degree and urgency of Iraq's threat, he never expressed opposition to the invasion. Bremer, meanwhile, is said to have done more harm than good in Iraq. Feith also accuses Franks of being uninterested in postwar planning, and writes that Condoleezza Rice, Bush's national security adviser during most of Feith's time in office, failed in her primary task of coordinating policy on the war.

So he's basically blaming everybody but the Pentagon. I think Mr. Stovepipe doth protest too much.

Who does Usama bin Laden want to be the next president? More people think the terrorist leader wants Obama to win (30 percent) than think he wants Clinton (22 percent) or McCain (10 percent). Another 18 percent says it doesn’t matter to bin Laden and 20 percent are unsure

MIDDLETOWN, Pa. - An 18-year-old Elizabethtown man is charged with possessing a weapon of mass destruction and other offenses over a plastic egg explosion.

Police say he ignited a plastic egg filled with plastic air-gun pellets in a flea market, hitting at least five people and causing alarm. It happened Saturday afternoon at a Saturday's Market in Londonderry Township, Dauphin County.

Peggy Beckley, the vendor manager, says market employees chased the man into the parking lot and held him for police.

In addition to the weapon of mass destruction charge, the teen was charged with risking a catastrophe, recklessly endangering another person, disorderly conduct and simple assault.

Instead of blocking high-bandwidth Internet traffic, why not just charge a little more for it?

Time Warner Cable has confirmed that it will begin testing a tiered pricing structure for subscribers to its RoadRunner cable broadband service in Beaumont, Texas, later this year. Under the new billing model, subscribers' monthly fees would be based on how much bandwidth they use.

Alex Dudley, a spokesman for Time Warner, said that the move comes in response to the increasing use of bandwidth-intensive software applications, particularly peer-to-peer networks. Dudley said that occasional, unpredictable spikes in Internet traffic due to heavy downloads can impede overall network performance.

"At some point we have to put in place some mechanism that will allow us to serve all our customers equally," Dudley said in an interview with InternetNews.com.

"One of the things to consider is the impact that peer-to-peer software is having on the network."

So just because their broadband networks are eons behind the networks provided by services in other countries for practically nothing, they are now charging people more to download more than five gigs a month? Well, if other broadband providers are smart, they would use this opportunity to attract customers away from AO-Hell-TimeWarner. But seeing as how the cable companies are pretty much cartels, they'll all just use this as a welcomed opportunity to make themselves more money.

The folks who invented the credit score for lenders are hard at work developing a similar tool for hospitals and other health care providers.

The project, dubbed “MedFICO” in some early press reports, will aid hospitals in assessing a patient’s ability to pay their medical bills. But privacy advocates are worried that the notorious errors that have caused frequent criticism of the credit system will also cause trouble with any attempt to create a health-related risk score. They also fear that a low score might impact the quality of the health care that patients receive.

. . .Several published reports have described Healthcare Analytics product as a MedFICO score, computed in a way that would be familiar to those who've used credit scores. The firm is gathering payment history information from large hospitals around the country, according to a magazine called Inside ARM, aimed at “accounts receivable management” professionals. It will then analyze that data to predict how likely patients will be to pay future medical bills. As with credit reports and scores, patients who've failed to pay past bills will be deemed less likely to pay future bills.

The idea sounds ominous to Pam Dixon, who runs the World Privacy Forum, which studies medical privacy issues.

"This is a bad idea and I don't think this benefits the consumer at all," Dixon said. "And what about victims of medical ID theft? Are we going to deny treatment to these people because they have a terrible MedFICO score?"

So which is it? Is health care a human right or a commodity reserved for those able to pay for it. The corporate pigs at the HMOs already have their answer, what's yours?

Limbaugh:…Obama is holding his own against both of them–doing more than his share of the “spade” work. Maybe even gaining ground at the moment. Using not only the spade ladies and gentleman—that when he finishes with the “spade” in the garden of corruption planted by the Clinton’s, he turns to the “hoe.” And so the spade work and his expertise using a hoe.